13 de abril de 2011

Monitoring guidelines: a missed opportunity?

Anaesthesia, 2007, 62, pages 857–858
A. Simpson, N. Levy
West Suffolk Hospital

We read with interest the recent AAGBI recommendations for standards of monitoring during anaesthesia and recovery [1]. We appreciate that the introduction of most routine monitoring during anaesthesia has not been subjected to rigorous randomised controlled investigation. The progressive reduction in anaesthesia-related morbidity and mortality is therefore linked to monitoring by association only. However, more recent developments in monitoring have been subjected to randomised controlled trials. Of particular interest to us is the use of cardiac output monitors during the operative period, for which Grade A evidence is available for their use in reducing hospital length of stay and morbidity [2–7]. No specific recommendation for cardiac output monitoring is made in the AAGBI guidelines. We suggest that this represents a significant missed opportunity for the introduction of such monitoring as standard for major surgical procedures, as this would enable targeted fluid management to optimise tissue perfusion intra-operatively, reduce hospital length of stay after major surgery and lead to a reduction in overall morbidity [2–7].

A number of cardiac output monitoring devices are available [2]. Pulmonary artery catheterisation is still cited as the ‘gold standard’ of cardiac output monitoring, but there are concerns regarding its use and effect on patient outcome [8]. The aim of intra-operative cardiac output monitoring is to optimise tissue perfusion and oxygen delivery to organs during the surgical insult, whilst avoiding the consequences of fluid overload. Conventional monitoring of cardiovascular status including the central venous pressure (CVP) is insufficiently sensitive to detect deficits in perfusion, and in studies comparing the use of cardiac output monitoring verses CVP monitoring, those patients that were optimised with cardiac output monitoring do considerably better than those patients whose treatment was guided using the CVP [5–7].

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